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Sansotta N, Agazzi R, Sonzogni A, Colledan M, Ferrari A, D'Antiga L. Subclinical biliary strictures as a cause of long-term allograft dysfunction in children who underwent liver transplantation. Am J Transplant 2021; 21:391-399. [PMID: 32808452 DOI: 10.1111/ajt.16270] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 08/12/2020] [Accepted: 08/12/2020] [Indexed: 01/25/2023]
Abstract
We aimed to evaluate the role of liver biopsy to predict subclinical biliary strictures (BS) and assess the impact of BS on long-term allograft dysfunction following liver transplantation in children (LT). We reviewed all liver biopsies performed from 2012-2018. Percutaneous transhepatic cholangiography (PTC) was performed in patients presenting cholangiolar proliferation on cytokeratin-7 stained sections. We performed 271 biopsies in 161 children (86% with a left lateral segment); 44/161 (27%) presented with diffuse or multifocal cholangiolar proliferation. Among them, a tight BS was confirmed in 38/44 (86%, 24% of total) and it was managed by balloon dilatation. Cholangiolar proliferation showed a positive predictive value (PPV) for BS of 86.4%. Levels of alkaline phosphatase >325 IU/L predicted BS (P = .007). Dilatation of intrahepatic bile ducts on ultrasound was found only in 44% of patients with BS. Following a median follow-up of 9.2 years, only 15/38 (39%) patients resolved the BS. In conclusion subclinical BS is very common and probably underdiagnosed in these patients. Histological evidence of cholangiolar proliferation detectable by cytokeratin-7 immunostain should be preferred to liver function tests and ultrasound to suspect BS. BS in this setting should be regarded as a main cause of long-term allograft dysfunction.
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Affiliation(s)
- Naire Sansotta
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Roberto Agazzi
- Interventional Radiology, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | | | - Michele Colledan
- General and Transplant Surgery, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Alberto Ferrari
- FROM Research Foundation, Statistics, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Lorenzo D'Antiga
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
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Perito ER, Martinez M, Turmelle YP, Mason K, Spain KM, Bucuvalas JC, Feng S. Posttransplant biopsy risk for stable long-term pediatric liver transplant recipients: 451 percutaneous biopsies from two multicenter immunosuppression withdrawal trials. Am J Transplant 2019; 19:1545-1551. [PMID: 30614623 PMCID: PMC6482080 DOI: 10.1111/ajt.15255] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/20/2018] [Accepted: 12/27/2018] [Indexed: 01/25/2023]
Abstract
Although liver biopsy is the gold standard for assessing allograft health, its attendant risk has deterred its use in routine monitoring of stable liver transplant recipients during long-term follow-up. We utilized prospectively collected data on adverse events from 2 clinical trials of immunosuppression withdrawal to quantify the risk of liver biopsy in pediatric liver transplant recipients. The trials included 451 liver biopsies in 179 children. No biopsies led to bleeding requiring transfusion or intervention, suggesting a clinically significant bleeding risk of <0.8%. Complications were reported in 5.5% of biopsies (95% CI 3.6%-8.1%): 5.8% (21/363) of protocol biopsies and 4.5% (4/88) of for-cause biopsies (P = .80). Mild complications occurred in 1.8% of biopsies, moderate in 1.8%, and severe in 2.0%. The majority of complications (89%) resolved within 1 week. Six of 9 (67%) severe complications were related to biliary issues; 5 were episodes of cholangitis. Biopsy-related cholangitis occurred only in children with underlying biliary strictures. Overall, biopsy-related complications were infrequent and resolved quickly. Severe complications were rare, with occult biliary stricture as the dominant driver. Our study provides evidence for clinicians who are considering the risk vs benefit of surveillance liver biopsies in pediatric liver transplant recipients.
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Affiliation(s)
- Emily R. Perito
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Mercedes Martinez
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Yumirle P. Turmelle
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - John C. Bucuvalas
- Department of Pediatrics, Icahn School of Medicine at Mt. Sinai and the Recanti-Miller Transplant Institute, New York, NY, USA
| | - Sandy Feng
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
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Halac E, Dip M, Quiñonez E, Alvarez F, Espinoza JL, Romero P, Nievas F, Maurette R, Luque C, Matus D, Surraco P, Fauda M, McCormack L, Mattera FJ, Gondolesi G, Imventarza O. Split liver transplantation: Report of right and left graft outcomes from a multicenter Argentinean group. Liver Transpl 2016; 22:63-70. [PMID: 26369269 DOI: 10.1002/lt.24338] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 07/18/2015] [Accepted: 08/27/2015] [Indexed: 02/07/2023]
Abstract
Grafts from split livers (SLs) constitute an accepted approach to expand the donor pool. Over the last 5 years, most Argentinean centers have shown significant interest in increasing the use of this technique. The purpose of this article is to describe and analyze the outcomes of right-side grafts (RSGs) and left-side grafts (LSGs) from a multicenter study. The multicenter retrospective study included data from 111 recipients of SL grafts from between January 1, 2009 and December 31, 2013. Incidence of surgical complications, patient and graft survival, and factors that affected RSG and LSG survival were analyzed. Grafts types were 57 LSG and 54 RSG. Median follow-up times for LSG and RSG were 46 and 42 months, respectively. The 36-month patient and graft survivals for LSG were 83% and 79%, respectively, and for RSG were 78% and 69%, respectively. Retransplantation rates for LSG and RSG were 3.5% and 11%, respectively. Arterial complications were the most common cause of early retransplantation (less than 12 months). Cold ischemia time (CIT) longer than 10 hours and the use of high-risk donors (age ≥ 40 years or body mass index ≥ 30 kg/m2 or ≥ 5 days intensive care unit stay) were independent factors for diminished graft survival in RSG. None of the analyzed variables were associated with worse graft survival in LSG. Biliary complications were the most frequent complications in both groups (57% in LSG and 33% in RSG). Partial grafts obtained from liver splitting are an excellent option for patients in need of liver transplantation and have the potential to alleviate the organ shortage. Adequate donor selection and reducing CIT are crucial for optimizing results.
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Affiliation(s)
- Esteban Halac
- Servicio de Trasplante Hepático, Hospital Nacional de Pediatría Juan P. Garrahan, Buenos Aires, Argentina.,Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Marcelo Dip
- Servicio de Trasplante Hepático, Hospital Nacional de Pediatría Juan P. Garrahan, Buenos Aires, Argentina.,Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Emilio Quiñonez
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Fernando Alvarez
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Johana Leiva Espinoza
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Pablo Romero
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Franco Nievas
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Rafael Maurette
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Carlos Luque
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Daniel Matus
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Paz Surraco
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Martin Fauda
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Lucas McCormack
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Francisco J Mattera
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Gabriel Gondolesi
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Oscar Imventarza
- Servicio de Trasplante Hepático, Hospital Nacional de Pediatría Juan P. Garrahan, Buenos Aires, Argentina.,Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
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Feier FH, da Fonseca EA, Seda-Neto J, Chapchap P. Biliary complications after pediatric liver transplantation: Risk factors, diagnosis and management. World J Hepatol 2015; 7:2162-2170. [PMID: 26328028 PMCID: PMC4550871 DOI: 10.4254/wjh.v7.i18.2162] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 07/30/2015] [Accepted: 08/11/2015] [Indexed: 02/06/2023] Open
Abstract
The expanded indications of partial grafts in pediatric liver transplantation have reduced waiting list mortality. However, a higher morbidity is observed, including an increased rate of biliary complications (BCs). Factors such as the type of graft, the preservation methods applied, the donor characteristics, the type of biliary reconstruction, and the number of bile ducts in the liver graft influences the occurrence of these complications. Bile leaks and strictures comprise the majority of post-transplant BCs. Biliary strictures require a high grade of suspicion, and because most children have a bileo-enteric anastomosis, its diagnosis and management rely on percutaneous hepatic cholangiography and percutaneous biliary interventions (PBI). The success rates with PBI range from 70% to 90%. Surgery is reserved for patients who have failed PBI. BCs in children after liver transplantation have a prolonged treatment and are associated with a longer length of stay and higher hospital costs. However, with early diagnosis and aggressive treatment, patient and graft survival are not significantly compromised.
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